Fri, 07/03/2020 - 3:00am

Lung protective ventilation limiting tidal volume and plateau pressure improves survival in ARDS. The application of positive end-expiratory pressure (PEEP) further stabilizes the lung by preventing alveolar collapse during expiration, thereby reducing cyclic atelectasis. However, the optimal approach to PEEP titration to minimize ventilator-induced lung injury (VILI) has not been delineated. The EPVent-1 trial demonstrated that esophageal pressure-guided PEEP titration was feasible and safe with a trend toward increased survival and improved oxygenation in mild to moderate ARDS. However, interest in esophageal manometry in ARDS was deflated by the more recent EPVent-2 trial demonstrating no improvement in a composite outcome incorporating mortality and ventilator-free days in patients with moderate to severe ARDS. A new randomized control trial published last week by Wang et al. examined the role of esophageal manometry-guided PEEP titration in a novel subset of severe ARDS patients treated with VV ECMO. 

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Wed, 07/01/2020 - 12:10am

A 5 yo with a hx of sickle cell disease presents with diffuse pain.

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Mon, 06/29/2020 - 5:00am

Not a common inner-city emergency, but certainly something you'll see elsewhere. Removing an embedded fishhook can be surprisingly tricky - here are a few methods to know!

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Sat, 06/27/2020 - 5:00am

A 65 year old fem

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Fri, 06/26/2020 - 3:00am

A 46 year old woman arrives at the ED with hives, hypotension, difficulty breathing, and stridor after eating dinner with her family.  She is allergic to shrimp, and thought she had avoided it when she ordered from her favorite restaurant.  However, shrimp dishes are on the menu and she wonders if there was cross contamination.  Unfortunately, she couldn’t find her epinephrine auto-injector at home so her family drove her to the ED.  Immediately recognizing anaphylaxis, you give her a dose of IM epinephrine and she improves within several minutes.  After seeing she has stabilized, you wonder how long should she be observed and what the evidence is behind the use of antihistamine and glucocorticoid therapy.

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Wed, 06/24/2020 - 7:00am

A 75 yo M presents to the ED after a mechanical fall w/ L facial pain and swelling.

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Tue, 06/23/2020 - 1:00pm

Independently interpreting plain film imaging is an essential skill for the Emergency Medicine provider. Among the most notorious of injuries likely to be missed is the Maisonneuve fracture. In this post we demonstrate the "can't miss" imaging findings to ensure that you don't make the mistake of thinking this is "just an ankle sprain!"

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Mon, 06/22/2020 - 5:00am

Nails and nailbed injuried can be surprisingly complex. A good foundation of nail anatomy and function will help you understand how to treat various nail conditions better.

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Sat, 06/20/2020 - 7:30pm

A 21 year old fem

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Fri, 06/19/2020 - 2:00am

 

We do not often give thought to the factors controlling our circadian rhythm. And yet the circadian system modulates many physiologic systems, including brain arousal, cardiovascular function, sympathetic tone, appetite, metabolism and immune system function. Similar to the sinoatrial node pacing the heart, the suprachiasmatic nucleus located in the hypothalamus serves as the central pacemaker for the circadian rhythm, directing sleep, motor activity, temperature and autonomic tone. Rhythmic release of melatonin from the pineal gland helps drive this central clock in addition to other circadian biomarkers, including cortisol and core body temperature. In healthy individuals, plasma melatonin concentrations typically measure 10-fold higher at night than during the daytime. How does critical illness affect circadian rhythm, specifically melatonin secretion?

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